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To identify risk factors for polymicrobial bloodstream infections (BSIs) in pediatric bone marrow transplant (BMT) outpatients attending a newly constructed clinic affiliated with a children's hospital.
Methods.
All 30 outpatients treated at a new BMT clinic during September 10-21, 2007, were enrolled in a cohort study. The investigation included interviews, medical records review, observations, and bacterial culture and molecular typing of patient and environmental isolates. Data were analyzed using exact conditional logistic regression.
Results.
Thirteen patients experienced BSIs caused by 16 different, predominantly gram-negative organisms. Presence of a tunneled catheter (odds ratio [OR], 19.9 [95% confidence interval {CI}, 2.4-∞), catheter access (OR, 13.7 [95% CI, 1.8-∞]), and flushing of a catheter with predrawn saline (OR, 12.9 [95% CI, 1.0-766.0]) were independently associated with BSI. The odds of experiencing a BSI increased by a factor of 16.8 with each additional injection of predrawn saline (95% CI, 1.8-827.0). Although no environmental source of pathogens was identified, interviews revealed breaches in recommended infection prevention practice and medication handling. Saline flush solutions were predrawn, and multiple doses were obtained from single-dose preservative-free vials to avoid delays in patient care.
Conclusion.
We speculate that infection prevention challenges in the new clinic, combined with successive needle punctures of vials, facilitated extrinsic contamination and transmission of healthcare-associated pathogens. We recommend that preservative-free single-use vials not be punctured more than once. Use of single-use prefilled saline syringes might prevent multiuse of single-use saline vials. Storage of saline outside a medication supply system might be advisable. Before opening new clinic facilities, hospitals should consider conducting a mock patient flow exercise to identify infection control challenges.
To describe investigation of a tightly clustered outbreak of invasive group A streptococcal (GAS) disease associated with a high mortality rate in a long-term care facility (LTCF).
Design.
Cross-sectional carriage survey and epidemiologic investigation of LTCF resident and employee cohorts.
Setting.
A 104-bed community LTCF between March 1 and April 7, 2004.
Patients.
A cohort of LTCF residents with assigned beds at the time of the outbreak.
Interventions.
Reinforcement of standard infection control measures and receipt of chemoprophylaxis by GAS carriers.
Results.
Four confirmed and 2 probable GAS cases occurred between March 16 and April 1, 2004. Four case patients died. The final case occurred during the investigation, before the patient was determined to be a GAS carrier. No case occurred during the 6 months after the intervention. Disease was caused by type emm3 GAS; 16.5% of residents and 2.4% of employees carried the outbreak strain. Disease was clustered in 1 quadrant of the LTCF and associated with nonintact skin. GAS disease or carriage was associated with having frequent personal visitors.
Conclusions.
Widespread carriage of a virulent GAS strain likely resulted from inadequate infection control measures. Enhanced infection control and targeted prophylaxis for GAS carriers appeared to end the outbreak. In addition to employees, regular visitors to LTCFs should be trained in hand hygiene and infection control because of the potential for extended relationships over time, leading to interaction with multiple residents, and disease transmission in such residential settings. Specific attention to prevention of skin breaks and proper wound care may prevent disease. The occurrence of a sixth case during the investigation suggests urgency in addressing severe, large, or tightly clustered outbreaks of GAS infection in LTCFs.
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